May 2010 LTC Provider Bulletin No. 42 - TMHP.com

In This BulletinFiscal year-end closeout – Featured on page 6 of this issue is important information to help providers avoid Miscellaneous Claims before the annual August cutoff.

MDS 3.0 rollout – With release of Minimum Data Set 3.0 on target for October 1, DADS recommends that providers prepare for this transition from MDS 2.0 by attending a new MDS 3.0 workshop or webinar this summer. See page 2 for registration information.

New LTC TexMedConnect computer-based training (CBT) available now – The new CBT modules for Long Term Care TexMedConnect are now available with easy-to-follow instructions. The new CBT covers the full set of LTC TexMedConnect topics. Learn more in the article on Page 4.

Training reminders – There’s a handy new entry on Page 7 in the “Reminders” section that offers providers an at-a-glance overview of the types of training materials and other resources available on the LTC web page at www.tmhp.com/LTCPrograms/. Also see the Page 7 item on RUG Training Requirements to be sure RNs who need RUG training renew on time.

LTC News – Providers that don’t regularly monitor the LTC web page at www.tmhp.com/LTCPrograms/, might want to add it to their online bookmarks after reading the information in the box on page 2.

No. 52

P r o v i d e r B u l l e t i nLong Term Care

What’s New What’s New 22

Minimum Data Set (MDS) 3.0 Workshops Announced ......2

LTC News Notices ........................................................................................2

TexMedConnect Computer-Based Training Available Now ................................................................................................4

STAR+PLUS Expanding to Dallas and Tarrant Service Areas in Early 2011 .......................................................................................4

Updates Updates 55

MDS 3.0 Update ............................................................................................5

In This Corner In This Corner 66

Avoid Miscellaneous Claims; Start Preparing for FY11 ..........6

Reminders Reminders 77

Long Term Care (LTC) Training Materials and Resources ...7

Reminder for Resource Utilization Group (RUG) Training Requirements .................................................................................................7

How to Receive DADS Information Letter Posting Notices ................................................................................................................7

Important TexMedConnect Reference Information ............8

Tips for Account/User Linking .............................................................9

How TMHP Provider Representatives Can Help You ............9

Verify Eligibility with a MESAV Inquiry ........................................ 10

Providers Encouraged to Bill Electronically ............................. 10

Provider Resources 1Provider Resources 111

Provider Relations Representatives ............................................... 11

TMHP LTC Contact Information ....................................................... 12

DADS Contact Information ................................................................. 13

Index of Articles in Past Issues .......................................................... 16

Acronyms In This Issue .......................................................................... 17

Use of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure:

“Current Procedural Terminology (CPT) is copyright 2009 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.”

The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2008 American Dental Association. All Rights Reserved. Applicable FARS/DFARS apply.”

May 2010 No. 42

IN THIS EDITION

What’s New

Minimum Data Set (MDS) 3.0 Workshops Announced Important new Long Term Care (LTC) workshops are currently being developed for summer/fall of 2010. These new half-day workshops will focus on changes for the Minimum Data Set (MDS) Long Term Care Medicaid information section and Medical Necessity and Level of Care (MN and LOC) assessments. Two series of LTC workshops are offered; one for nursing facility/hospice providers, and one for Community Services Waiver Programs providers. An overview of each of these workshops is provided below.

In addition to the live workshops, instructor-led online webinar versions of both workshop series will be offered. Without leaving the office, providers can participate in a web-based, instructor-led webinar version of these LTC workshops. Alternatively, providers will be able to replay a recorded version of the first webinar offered in the series for either nursing facility/hospice or Community Services Waiver Programs.

Beginning July 2010, providers are encouraged to monitor future announcements on the TMHP website

at www.tmhp.com/LTC Programs/ for these workshop dates which are currently targeted to begin in early August.

The schedule for LTC training opportunities is posted on the TMHP website 30 days prior to the first workshop date. An LTC News notice will be posted when dates and locations are announced.

Providers can check workshop schedules and register online for LTC workshops at www.tmhp.com/LTC Programs/ by scrolling to “LTC Program Resources” on the TMHP website and clicking on Register for a Workshop.

Providers are encouraged to register early for these MDS 3.0 workshops.

Because seating and materials are limited, providers should check seat availability and register at least 10 days prior to the desired workshop date. Online registration helps providers select LTC workshops to avoid inadver-tently traveling to an acute-care workshop.

To register for a webinar, attendees should go to www.tmhp.com/LTC Programs/ and click on the Register for a Workshop link (preferred). Alternatively, a provider can fax the applicable registration form to 1-512-506-7002. When faxing a registration request, complete all fields and add one of the following, as appropriate. Please be sure to fill in the desired webinar date on top of the

“Provider Name” field of the registration form:

“Webinar MM/DD/2010” for the Community Services Waiver Programs Workshop Webinar

“Webinar MM/DD/2010” for the Nursing Facility/Hospice Workshop Webinar

MDS 3.0 LTC Nursing Facility/Hospice Provider Workshop The MDS 3.0 LTC Nursing Facility/Hospice workshop will present very important information that will enable providers to submit forms and assessments accurately and efficiently. This course will offer providers a better understanding of the changes associated with the new MDS 3.0 assessment and the reason the new assessment is being released on October 1, 2010. This workshop will also provide education on benefits of the LTC Online Portal to complete and submit Long Term Care

LTC News Notices

The “News” section at www.tmhp.com/

LTCPrograms/ provides valuable information on

updates and enhancements to the Long Term Care

(LTC) Online Portal, as well as to LTC TexMed‑

Connect. All LTC providers are encouraged to

monitor this section frequently to be informed

of upcoming system changes. Other helpful

information found in the “News” section includes

links to the Long Term Care Provider Bulletin,

Department of Aging and Disability Services

(DADS) Information Letters, information on

scheduled LTC workshops, system maintenance

or downtime, and notifications of system issues.

Providers can review previous “News” notices

by clicking the link found in the “LTC Archive”

section.

LTC Provider Bulletin, No. 42 2 May 2010CPT only copyright 2009 American Medical Association. All rights reserved.

What́ s New

Medicaid Information (LTCMI) section. Workshop topics will include:

Understanding the changes that have occurred as a result of the new MDS 3.0 assessment.

Understanding why a new version of the MDS assessment is being released.

Recognizing the timelines associated with submitting, and modifying MDS 2.0 assessments.

Basic LTC Online Portal functions.

Searching for MDS 2.0 and the new MDS 3.0 assessments using the “Form Status Inquiry” and

“Current Activity” features.

Printing completed MDS 2.0 and the new MDS 3.0 assessments.

Medical Necessity (MN) process including the fair hearing process.

Long Term Care Medicaid Information (LTCMI).

Finding and completing the new MDS 3.0 LTC Medicaid Information (LTCMI) section.

Additional or changed LTCMI fields as a result of the new MDS 3.0 assessment.

Changes to the MDS extraction process from hourly to nightly.

Submission of the updated Preadmission Screening and Resident Review (PASARR) and how to determine when a PASARR Screening is required.

How to prepare and complete Purpose Codes E and M, and Forms 3071, 3074, 3618, and 3619.

Assessment statuses.

Managing the provider workflow.

Resolving submission and Medicaid processing errors to include new provider message codes.

Texas State University (TXST) Resource Utilization Group (RUG) training requirements.

Where to access additional resources regarding the new MDS 3.0 assessment.

MN and LOC 3.0 Community Services Waiver Programs WorkshopThe MN and LOC 3.0 LTC workshop for Community Services Waiver Programs providers will offer valuable information on the changes associated with the upcoming implementation of the new MN and LOC 3.0 Assessment and the reason the new assessment is being introduced. This new assessment will be implemented October 1, 2010. Workshop topics will include:

MN and LOC 3.0 changes.

Understanding why a new version of the MN and LOC Assessment is being released.

Basic LTC Online Portal functions.

Searching for MN and LOC 2.0 and the new MN and LOC 3.0 Assessments using the “Form Status Inquiry” and “Current Activity” features.

Printing completed MN and LOC 2.0 and the new MN and LOC 3.0 Assessments.

Locating step-by-step instructions for using the LTC Online Portal through the “Help” link.

Medical Necessity (MN) process including the fair hearing process.

Additional or changed LTCMI fields of the new MN and LOC Assessment.

Submitting the new MN and LOC 3.0 Assessment through the LTC Online Portal.

Identifying assessment statuses.

New statuses being implemented with MN and LOC 3.0.

Managing provider workflow.

Texas State University (TXST) RUG training requirements.

Where to access additional resources regarding the new MN and LOC 3.0 Assessment.

May 2010 3 LTC Provider Bulletin, No. 42CPT only copyright 2009 American Medical Association. All rights reserved.

What́ s New

Access Reform (STAR)+PLUS Medicaid managed care models, HHSC has determined that the most appropriate, cost-effective model to implement in response to the legislative mandate is the STAR+PLUS program. HHSC intends to expand the STAR+PLUS program into the Dallas and Tarrant service areas in early 2011.

The Dallas service area includes the following seven counties: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall.

The Tarrant service area includes the following six counties: Denton, Hood, Johnson, Parker, Tarrant, and Wise.

Current ICM 1915(c) Waiver (ICMW), Primary Home Care, and Day Activity and Health Services providers in the Dallas and Tarrant service areas will be affected by this implementation. For further information, refer to Department of Aging and Disability Services (DADS) Information Letter No. 10-42, Expansion of the STAR+PLUS Program, published on the DADS Letters to Providers website (www.dads.state.tx.us/providers/communications/letters.cfm). This letter explains the impact of this STAR+PLUS expansion and actions to be taken by all affected parties in the upcoming months.

Decision to Expand STAR+PLUS

The HHSC analysis of current Medicaid managed care models determined that STAR+PLUS is the only proven approach that meets all criteria specified by the Legislature, including cost effectiveness and integration of services. The STAR+PLUS model was created specifically to serve the ABD population, providing fully integrated acute and long term services and supports (LTSS). The STAR+PLUS program began operating in Harris County in 1998. In 2007, STAR+PLUS was expanded to serve 29 counties in the Bexar, Nueces, Travis, and Harris Expansion Service Areas. There are over 164,000 clients currently being served in the STAR+PLUS program.

Customer service surveys of STAR+PLUS members indicate high levels of satisfaction with the STAR+PLUS program. In particular, members report high levels of satisfaction with the assistance they receive from their service coordinator; indicating that it is easy to get help from a service coordinator when they need it.

TexMedConnect Computer-Based Training Available NowThe Texas Medicaid & Healthcare Partnership (TMHP) has released a series of computer-based training (CBT) modules to replace the TexMedConnect Workshop. The CBT modules focus on basic TexMedConnect tasks performed by Long Term Care (LTC) providers. Benefits of the new approach include providing online, on-demand training information so providers learn TexMedConnect at a time that is convenient for them, rather than having to wait for scheduled training. An additional benefit is that the CBT is divided into individual modules. This allows participants to directly access specific topics based on their needs rather than having to attend offsite training.

Participants must create an account and register before they are able to view the module. An evaluation link is also provided within the CBT.

The TexMedConnect CBT is available at the TMHP website on the LTC page at www.tmhp.com/LTC Programs/ and on the Online Learning Center page at www.tmhp.com/Online%20Learning/default.aspx.

STAR+PLUS Expanding to Dallas and Tarrant Service Areas in Early 2011The Health and Human Services Commission (HHSC) is required by the 2010-2011 General Appropriations Act (Article II, Special Provisions, Section 46, S.B. 1, 81st Legislature, Regular Session, 2009), to implement the most cost-effective, integrated managed care model for Aged, Blind, and Disabled (ABD) Medicaid clients in the Dallas and Tarrant service areas.

In May 2009, HHSC and Evercare of Texas ended their contract for the operation of the Integrated Care Management (ICM) program, which provided services to more than 75,000 ABD Medicaid clients in the Dallas and Tarrant service areas.

As the result of subsequent analysis of the ICM, Primary Care Case Management (PCCM), and State of Texas


What́ s New

STAR+PLUS has been shown to constrain costs while maintaining quality of care for its members. Studies of STAR+PLUS members conducted by the Institute for Child Health Policy have shown that, compared to clients in traditional Medicaid, STAR+PLUS members had fewer hospitalizations and were less likely to visit the emergency room. STAR+PLUS members generally have lower health care costs overall than clients in non-capitated programs.

Procurement After soliciting stakeholder feedback on the expansion of STAR+PLUS into the Dallas and Tarrant service areas, HHSC released a request for proposal (RFP) on November 25, 2009, and anticipated making the tentative contract awards in April 2010. HHSC expects to contract with at least two health plans in each service area to provide members with a choice of plans and provider networks.

CommunicationsFor more information regarding the STAR+PLUS expansion, please refer to the resources available on the HHSC STAR+PLUS Expansion website at www.hhsc.state.tx.us/medicaid/SP_DallasTarrantExpansion.shtml. DADS will link to this site to provide updates as that information becomes available.

DADS plans to hold LTSS provider meetings regarding STAR+PLUS expansion later this year. DADS will also publish information regarding the transition of the ICMW, Primary Home Care (PHC), and Day Activity and Health Services (DAHS) programs into the STAR+PLUS program on the DADS website at www.dads.state.tx.us/providers/.

Updates

MDS 3.0 UpdateThe federal Centers for Medicare & Medicaid Services (CMS) plan to convert from Minimum Data Set (MDS) 2.0 to MDS 3.0 effective October 1, 2010. When MDS 3.0 is implemented, the federal 3.0 Resident Assessment Instruments (RAIs) and the Texas Long Term Care Medicaid Information (LTCMI) will replace the current MDS 2.0 assessment instruments and associated LTCMI section. An updated Medical Necessity and Level of Care (MN and LOC) assessment will be developed based on MDS 3.0 for release with the nursing facility (NF) changes in October 2010.

Project StatusThe Texas Medicaid & Healthcare Partnership (TMHP) is completing the design and development phases of the project by documenting the Functional Design for the following areas:

New Long Term Care (LTC) Online Portal screens for the MDS 3.0 Nursing Facility assessment and the Community Services Waiver Programs MN and LOC 3.0 assessment.

Changes to the Form Status Inquiry and Current Activity to allow providers to search for the new assessments.

New nursing facility MDS receipt process from the federal MDS database. The MDS 3.0 Assessments will be transmitted once-a-day to the State, making the assessments available in the LTC Online Portal 24 to 48 hours after acceptance by the federal CMS.

Programs Affected by the TransitionNF/Hospice

Community Services Waivers: Community-Based Alternatives (CBA), Program of All-Inclusive Care for the Elderly (PACE), Consolidated Waiver Program (CWP), Medically Dependent Children Program (MDCP), Integrated Care Management 1915(c) Waiver (ICMW) recipients, and State of Texas Access Reform (STAR)+PLUS.


Need Help? For questions about the information in this

bulletin, please call the TMHP‑LTC Call Center/

Help Desk at 1‑800‑626‑4117. TMHP operates

the TMHP Call Center/Help Desk and provides

telephone support to LTC providers. The TMHP

Call Center/Help Desk is available Monday

through Friday, 7:00 a.m to 7:00 p.m., Central

Time (excluding holidays).

What’s New / Updates

Training StrategyA combination of instructor-led training and online web-based training will be made available during the training phase, currently planned for summer 2010, including:

TMHP workshops for NF/Hospice providers, Community Services Waiver Program providers, and state personnel focused on the function of the LTC Online Portal system.

Online Resource Utilization Group (RUG) training updated to reflect MDS 3.0. RUG training is required for LTC Online Portal submission.

Additional InformationFurther MDS 3.0 information can be found on the following websites:

The federal CMS website at www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp

The DADS MDS 2.0 to 3.0 Project website at www.dads.state.tx.us/providers/MDS/mds3/index.html

Questions concerning MDS 3.0 can be sent to: [email protected].

In This Corner

Avoid Miscellaneous Claims; Start Preparing for FY11The State of Texas fiscal year (FY) runs from September 1 through August 31. In the upcoming FY 2011, any claims submitted for FY08 (September 1, 2007, through August 31, 2008) that are received by the Texas Medicaid & Healthcare Partnership (TMHP) on or after this year’s fiscal year-end cutoff in August, become Miscellaneous Claims that cannot be paid through the standard Claims Management System (CMS) payment process. A Miscellaneous Claim occurs when the service dates on a claim are older than two FYs before the current FY. Miscellaneous Claims for services that are

less than eight years old or those that total less than $50,000 owed to a single legal entity are paid on a first-come, first-served basis using funds that are appropriated during each legislative session. Any Miscellaneous Claim over $50,000 or for services more than 8 years old cannot be paid except as a special line item in the state budget.

If a provider submits a claim that has already become a Miscellaneous Claim, the claim is processed as a Transferred Status claim and appears on Remittance and Status (R&S) Reports with a “T” status. The provider should not calculate T status claims in the Total Paid Amount on the R&S Report. T status claims must be submitted to the Texas Comptroller for Public Accounts for processing and payment, and are subject to the funding limitations described above. The Department of Aging and Disability Services (DADS) Provider Claims Services (PCS) Unit processes T status claims on a monthly basis. Assistance in filing an Application for Payment of Claim Against the State of Texas may be obtained by contacting PCS at 1-512-438-2200, Option 3 (for nursing facilities, hospices, and Intermediate Care Facilities for Persons with Mental Retardation [ICF-MR]) and Option 4 (Community Care for the Aged and Disabled).

Providers should submit their claims in a timely manner to avoid significant delays in payment caused by Miscel-laneous Claims. It is also useful to review R&S Reports each week.

For more information on Miscellaneous Claims, refer to DADS Information Letter No. 09-72- “TMHP Remittance and Status (R&S) Report Information,” which is available on the DADS website at www.dads.state.tx.us/providers/communications/2009/letters/IL2009-72.pdf.

For fiscal year-end cutoff date information, providers should monitor online notices published on the LTC web page at www.tmhp.com/LTCPrograms/ and the DADS Information Letter notices at www.dads.state.tx.us/providers/communications/letters.cfm.


Updates / In This Corner

Reminders

Long Term Care (LTC) Training Materials and Resources The following training materials are available on the LTC website at www.tmhp.com/LTCPrograms/:

Workshop Participant Guide - The Workshop Participant Guide provides information regarding the purpose of each form or assessment type and when to submit the various forms and assessments. There are two guides available, one for nursing facility/hospice providers and the other for Community Services Waiver Programs providers.

LTC Online Portal User Manual - The LTC Online Portal User Manual provides step-by-step instructions on how to use the various features of the LTC Online Portal. There are two manuals available, one for nursing facility/hospice providers and the other for Community Services Waiver Programs providers.

LTC TexMedConnect Workbook - The LTC TexMedConnect Workbook provides an overview of the various features of TexMedConnect for LTC providers.

LTC User Manual for Paper Submitters - This user manual is published annually for LTC providers that use the LTC Claim Form 1290 to submit paper claims. It provides detailed instructions for completing the Form 1290.

Additional resources such as the Long Term Care Provider Bulletin, LTC Information Letters, and LTC Reference Codes are also available on the LTC web page at www.tmhp.com. Providers may also check the “What’s New” section of this bulletin for the latest articles and updates.

Reminder for Resource Utilization Group (RUG) Training RequirementsProviders are reminded that RUG training is required for registered nurses (RNs) who sign assessments as complete. RNs must successfully complete the required

RUG training to be able to submit assessments on the Long Term Care (LTC) Online Portal. Training is valid for two years and must be renewed by completing the online RUG training offered by Texas State University.

It can take from 2 to 7 business days to process and report completions of RUG training from Texas State University to the Texas Medicaid & Healthcare Partnership (TMHP), depending on current volume of enrollments and completions.

To register for the RUG training, or for more information, visit:

www.txstate.edu/continuinged/programs/Online-Programs/RUG-Training.html

How to Receive DADS Information Letter Posting NoticesProviders can sign up to receive e-mail updates from the Department of Aging and Disability Services (DADS) through the agency’s Gov Delivery e-mail system. You can do this one of two ways:

From the DADS homepage (www.dads.state.tx.us), click on the E-mail Updates tab in the center of the page and follow the directions. This link shows you all the categories for which DADS offers subscriptions.

From the DADS provider portal (www.dads.state.tx.us/providers), click on your provider type in the left navigation. Each provider homepage has an icon that says, “Sign up here for E-mail Updates.” This will automat-ically create a subscription to that particular provider site.

You can also manage your subscriptions—adding or deleting items for which you wish to subscribe—by using the link on the DADS homepage or by using the link at the bottom of any Gov Delivery message you have received.


Reminders

Important TexMedConnect Reference Information

returned in a user-friendly, formatted Microsoft Excel® file. The information is similar to the data in the PDF R&S Report format, but it is in Microsoft Excel® format. The primary use of this report is to provide specific claim data for an NPI/Contract Number in an easy-to-read format.

Who has Access: Only administrators can access this option.

Availability: The report file is available until a user downloads it from the FTP server. Important: After the file has been downloaded by a user, it will not be available for other users.

How to Use: R&S Reports are valuable tools for tracking billing activities. A successful business typically has good accounting practices, such as the reconciliation of R&S Reports. Agencies that do not reconcile their R&S Reports may be billing incorrectly, which can result in audits and penalties. It is the provider’s respon-sibility to ensure that all billing is accurate and that any problems or issues associated with the claim are resolved within the 12-month filing limitation. If the repayment of an invalid or inappropriate recoupment is not resolved within 12 months, it is subject to the 12-month filing limitation.

An invalid or inappropriate recoupment should be reported immediately by contacting Provider Claims Services (PCS) at 1-512-438-2200, Option 3 (for nursing facilities, hospices, and State Supported Living Centers), and Option 4 (Community Care for the Aged and Disabled).

Providers are encouraged to download their R&S Reports weekly. Each report is available for 90 days.

Sections: R&S Reports are divided into 3 sections:

The Non-Pending section contains HIPAA-compliance information that is based on the national procedure or revenue codes submitted on the claim. It also lists any adjustments made to the total provider payment. Providers will receive one R&S Report per warrant issued for the reporting period.

The Claim Activity section provides information about all finalized claims and claims still pending processing

Remittance and Status (R&S) Reports list all of the claims that were submitted and processed in a given week. R&S Reports are available every Monday, and each report contains information about the previous week’s claims activity. There are 3 ways to access an R&S Report. Providers should use the most appropriate one as outlined below.

PDF R&S ReportDescription: The R&S Report is in a portable document format (PDF). The report provides financial reconcil-iation information that is similar to what electronic providers used to receive, but in the same layout as the current paper R&S Report. The information can be printed or downloaded, but not manipulated. A report is generated for each unique National Provider Identifier (NPI)/Contract Number.

Availability: The report can be viewed online for up to 3 months. Three months after the posting date, the report will be removed from the website. Multiple users can access the report at any time.

ANSI 835 R&S Report (only for providers billing ANSI claims)Description: The American National Standards Institute (ANSI) 835 file is a Health Insurance Portability and Accountability Act (HIPAA)-compliant R&S Report format used by providers or third-party software and other “back-end” financial systems. The ANSI 835 file provides financial reconciliation information in a comma-delimited format. The information is downloaded in a flat file for use with software that can manipulate the data to meet a provider’s needs (e.g., third-party billing software, Microsoft Access™).

Availability: The report file is available until a user downloads it from the file transfer protocol (FTP) server. Important: After the file has been downloaded by a user, it will not be available for other users.

Claim Data ExportDescription: A claim data export is a “customized” user search that allows providers to request up to 3 months of claim data for the 3 previous years. The results are


Reminders

or payment. Finalized claims that make it through the claims payment process are either approved-to-pay or denied. This section includes the derived local billing code, units paid, billed amount, paid amount, and other details. Providers will receive only 1 Claim Activity section per reporting period. If more than 1 warrant is received in a particular week, the Claim Activity section may correspond to multiple Non-Pending sections.

The Non-Pending and Claim Activity sections outline which claims were processed, the national code billed, the local bill code derived, and the payment amount for the services based on the derived bill code. This is the only way to determine whether the system derived the correct bill code for payment.

The Financial Summary section provides warrant information and warrant amounts for the reporting period.

To accurately assess claim activity for the reporting period, all 3 sections must be used.

The number of warrants issued and, indirectly, the number of Non-Pending sections to look for is provided in the Financial Summary section.

An American National Standards Institute (ANSI) 835 Version of the R&S Report is also available for 90 days through TexMedConnect.

Additional details may be found in the February 2009 LTC TexMedConnect Quick Reference Guide on the TMHP website at www.tmhp.com.

Tips for Account/User LinkingThe following instructions are provided to assist providers with linking one contract/provider to another.

There are several reasons why one provider might want to link their contract/provider number to another:

A Department of Aging and Disability Services (DADS) contract/provider number has been changed. The old contract number is linked to the new number for functions such as viewing previous client eligibility and service authorization information, receiving claims status inquiries (CSI), and billing for previously unpaid services provided under the old contract number.

To give another provider permission to view your client’s Medicaid Eligibility Service Authorization Verification (MESAV) information.

References: Providers should refer to the Website Security Provider Training Guide for detailed instructions on how to step through the linking process. Contact the Texas Medicaid & Healthcare Partnership (TMHP) at 1-800-626-4117 or 1-800-727-5436, Option 3, for assistance.

Initial criteria to link existing users:

Both providers must have a current TMHP account.

Linking of the contract must be done by the provider (the account administrator) who is granting permission to another provider to view his/her MESAV information. For purposes of these instructions, the provider linking the contract is referred to as the administrator, and the provider being linked is referred to as the user.

Detailed information may be found in the February 2009 Long Term Care (LTC) TexMedConnect Quick Reference Guide on the TMHP website at www.tmhp.com.

How TMHP Provider Representatives Can Help You

When Long Term Care (LTC) providers need help,

the Texas Medicaid & Healthcare Partnership

(TMHP) is the main resource for general inquiries

about claim rejections/denials and how to use

automated TMHP provider systems (the LTC

Online Portal and TexMedConnect). See page 11

for a list of provider representatives in your area,

and pages 12 and 13 for a more comprehensive list

of the types of questions TMHP can address.


Reminders

Verify Eligibility with a MESAV Inquiry A Medicaid Eligibility Service Authorization Verification (MESAV) inquiry enables providers to electronically obtain eligibility and service authorization information through the TexMedConnect application. The Department of Aging and Disability Services (DADS) updates the Texas Medicaid & Healthcare Partnership (TMHP) files each weekday, so the most current MESAV information is always available.

MESAV inquiries provide valuable information about each individual enrolled in Long Term Care (LTC) programs. The inquiries enable providers to check services, units, eligibility, medical necessity, applied income/copayment, level of service in the Service Authorization System (SAS), and the effective dates for those authorizations.

Authorized providers can access information about a specific individual for a specific date range by requesting a MESAV inquiry. Information may be requested for dates spanning up to 3 months, but the information returned may extend beyond the 3-month range. Information that providers receive is based on the individual’s eligibility information available through TMHP. The Claims Management System (CMS) maintains confidentiality by returning information only to the provider authorized to perform requested services for that individual.

Providers should verify an individual’s eligibility with a MESAV inquiry before submitting a claim, making certain that the billed dates of service fall within the effective dates of the service authorization. One of the most common reasons claims are denied is that the dates of service are not within the service authorization period. If the Explanation of Benefits (EOB) states the individual is not authorized for services received, submit a MESAV inquiry to verify that the correct dates and services are on file with TMHP. Eligibility may be expired or on hold.

Providers submitting paper claims on a Form 1290 can verify an individual’s eligibility by contacting the TMHP Call Center/Help Desk at 1-800-626-4117, Option 1.

Providers Encouraged to Bill Electronically It’s fast. No more waiting by the mailbox or inquiring by telephone; know what’s happening to claims in less than 24 hours and receive reimbursement for approved claims within a week. TexMedConnect users can submit individual requests interactively and receive a response immediately.

It’s free. All electronic services offered by the Texas Medicaid & Healthcare Partnership (TMHP) are free, including TexMedConnect and its technical support and training.

It’s easy. TMHP offers free workshops for TexMed-Connect, Medicaid billing, and many other topics. A large file library of reference materials and manuals is available online at www.tmhp.com.

It’s safe. TMHP electronic data interchange (EDI) services use secure connections, just like the United States government, banks, and other financial institutions.

It’s accurate. TexMedConnect and most vendor software programs have features that let providers know when they’ve made a mistake, which means fewer rejected and denied claims. Rejected claims are returned with messages that explain what’s wrong, so the claim can be corrected and resubmitted right away.

It’s there when it’s needed. Electronic services are available day and night; from home, the office, or anywhere in the world.

It makes record keeping and research easy. Not only can TexMedConnect be used to send and receive claims, it can retrieve Electronic Remittance and Status (ER&S) Reports, perform claim status inquiries, and archive claims. TexMedConnect can generate and print reports on everything it sends, receives, and archives.

For more information about TMHP’s electronic services, call the TMHP Call Center/Help Desk at 1-800-626-4117, Option 3.


Reminders


Provider Resources

Provider Relations Representatives

TMHP is under contract to offer an array of services designed to inform and educate the provider community about TexMedConnect and claims filing procedures.

Providers can call TMHP with questions and to request on-site visits to address particular areas of provider concern. TMHP workshops are also offered specifically for LTC providers; for current schedules check the LTC homepage on the TMHP website at www.tmhp.com/ltc Programs.

The map on this page, and the table below, indicate TMHP provider relations representatives and the areas they serve. Additional information, including a regional listing by county, is available on the TMHP website at www.tmhp.com/Providers/default.aspx. Click on the Regional Support link (near the end of the list on the first column) and choose the applicable region.

Territory Regional Area Representative Telephone Number

1 Amarillo, Childress, and Lubbock TBD 1-512-506-62172 Midland, Odessa, and San Angelo Mindy Wiggins 1-512-506-34233 Alpine, El Paso, and Van Horn Alma Gonzales 1-512-506-35304 Del Rio, Eagle Pass, and Laredo Christina Salinas 1-512-506-72715 Brownsville, Harlingen, and McAllen Cynthia Gonzales 1-512-506-79916 Abilene, Brownwood, and Wichita Falls Cynthia Rowlett 1-512-506-70957 Brady, North Austin,* Round Rock, and Waco Rhonda Williams 1-512-506-76008 South Austin,* Bastrop, Buda, Guadalupe, San Marcos Yvonne Olivo 1-512-506-35269 Kerrville and San Antonio* Kathe Barrett 1-512-506-342210 Corpus Christi, San Antonio,* and Victoria Alan Brown 1-512-506-355411 Cleburne, Denton, Fort Worth, and Grayson Tamara House 1-512-506-799012 Corsicana, Dallas,* and Groesbeck Sandra Peterson 1-512-506-355213 Dallas,* Paris, and Whitesboro Demekia Merritt 1-512-506-357814 Texarkana and Tyler Trilby Foster 1-512-506-705315 Beaumont and Lufkin Gene Allred 1-512-506-342516 Bryan/College Station, Conroe, and Houston* Linda Wood 1-512-506-768217 Houston,* Ft. Bend Stephen Hirschfelder 1-512-506-344718 Chambers, Galveston, Brazoria, Houston,*

Wharton, and MatagordaMichael Duffee 1-512-506-3586

*Austin, Dallas, Houston, and San Antonio territories are shared by 2 or more provider representatives. These territories are divided by ZIP Codes. Refer to the TMHP website at www.tmhp.com for the assigned representative to contact in each ZIP Code.


Provider Resources

TMHP LTC Contact Information

For questions about… Choose…

General inquiriesUsing TexMedConnectCompleting Claim Form 1290Claim adjustmentsClaim status inquiriesClaim historyClaim rejection and denialsUnderstanding R&S Reports

Forms 3618 and 3619Forms 3071 and 3074RUG levelsMinimum Data Set (MDS)LTC Medicaid Information (LTCMI)Medical Necessity and Level of Care (MN and LOC) assessment

Option 1: Customer service/general inquiry

Medical necessity Option 2: To speak with a nurseTexMedconnect – technical issues, account access, portal issuesModem and telecommunication issuesProcessing provider agreementsVerifying that system screens are functioning

American National Standards Institute (ANSI) ASC X12 specifi-cations, testing, and transmissionGetting EDI assistance from software developers EDI and connectivityLTC Online Portal, including technical issues, account access, portal issues

Option 3: Technical support

Electronic submission of MDSElectronic transmission of Forms 3618 and 3619Electronic transmission of Forms 3071 and 3074Form Status InquiryTechnical issues

Transmitting formsInterpreting Quality Indicator (QI) ReportsCurrent Activity (formerly Weekly Status Report)MDS submission problems MN and LOC assessment submission problems

Option 3: Technical support

The Texas Medicaid & Healthcare Partnership (TMHP) Call Center/Help Desk operates Monday through Friday from 7 a.m. to 7 p.m., Central Time (excluding TMHP-recognized holidays).

When calling the TMHP Call Center/Help Desk, providers are prompted to enter their 9-digit Long Term Care (LTC) provider number using the telephone keypad. If calling from a rotary telephone, remain on the line for assistance. When the 9-digit LTC provider number is entered on the telephone keypad, the TMHP Call Center/Help Desk system automatically populates the TMHP representative’s screen with that provider’s specific information, such as name and telephone number.

Providers should have their 4-digit Vendor/Facility or Site Identification number available for calls about Forms

3618 and 3619, Minimum Data Set (MDS), Medical Necessity and Level of Care (MN and LOC) assessment, and Pre-Admission Screening and Resident Review (PASARR).

Providers must have a Medicaid or Social Security number and a medical chart or documentation for inquiries about a specific individual.

For questions, providers should call the TMHP Call Center/Help Desk at the following telephone numbers:

Austin local telephone number at 1-512-335-4729

Toll free telephone number (outside Austin) at 1-800-626-4117 or 1-800-727-5436

RUG Information

RUG Information

RUG Information

RUG Information

RUG Information

RUG Information


Provider Resources

For questions about… Choose…

New messages (banner) in audio format for paper submitters Option 4: Headlines/topics for paper submitters

Individual appealsIndividual fair hearing requests

Appeal guidelines Option 5: Request fair hearing

Replay for menu options Option 6: Replay options

DADS Contact InformationIf you have questions about… Contact…

12-month claims payment rule Community Care for Aged and Disabled Programs (CCAD)—Contract Manager

Institutional Services (NFs)—Provider Claims Services: 1-512-438-2200, Option 1

MR Services—Provider Claims Services: 1-512-438-2200, Option 1

Community Services contract enrollment E-mail: [email protected] Voice mail 1-512-438-3550 or unit support 1-512-438-2080

Institutional Services contract enrollment 1-512-438-2546Hospice Services contract enrollment E-mail: [email protected]

Voice mail 1-512-438-3550 or unit support 1-512-438-2080

MR Services contract enrollment 1-512-438-3553Cost report information (days paid and services paid) Use TexMedConnect to submit a batch of CSIs.Rate Analysis contacts Website: www.hhsc.state.tx.us/medicaid/programs/rad

/index.html Click the Long Term Care link and then select the appropriate program.

How to prepare a cost report (forms and instructions)/approved rates posted

Website: www.hhsc.state.tx.us/medicaid/programs/rad /index.html

How to sign up for or obtain direct deposit/electronic funds transfer

Accounting: 1-512-438-4310, 1-512-438-5595, or 1-512-438-3189

How to obtain IRS Form 1099-Miscellaneous Income Accounting: 1-512-438-3189 or 1-512-438-3970Medicaid eligibility, applied income, and name changes

Medicaid Eligibility (ME) Worker Integrated Eligibility and Enrollment (IEE) Call Center at telephone number 2-1-1

Website: www.hhs.state.tx.us/consolidation/IE/IE.shtmlObtaining a copy of LTC Claim Form 1290 Contract Manager or

Website: www.dads.state.tx.us/business/communitycare /infoletters/index.cfm under Community Care Information Letters


Provider Resources

If you have questions about… Contact…

Deductions and provider-on-hold questions CCAD—Contract Manager

Institutional Services (NFs)—Provider Claims Services: 1-512-438-2200, Option 3

Website: https://hhsportal.hhs.state.tx.us/wps/portal

MR Services: 1-512-438-3544Invalid or inappropriate recoupments for nursing facilities, hospices, and ICF-MRs

Provider Claims Services: 1-512-438-2200, Option 3

Status of warrant/direct deposit after a claim has been transmitted to Accounting (fiscal) by TMHP

Accounting: 1-512-438-3989 When calling Accounting, provide the document locator number (DLN) number assigned by TMHP.

Comptroller’s website: https://ecpa.cpa.state.tx.us Choose the State-to-Vendor-Payment Info-On-line-Search link.

Texas State University (TXST) Resource Utilization Group (RUG) training

The Office of Continuing Education:

Online course: 1-512-245-7118 or 1-512-245-2507 Website: www.txstate.edu/continuinged

RUG information Website: www.dads.state.tx.us/providers/TILEStoRUGS/Long Term Care (LTC) Third-Party Resources (TPR) including torts and trusts and/or annuities for which the state is the residual beneficiary

Provider Claims Services: 1-512-438-2200, option 4 Website: https://hhsportal.hhs.state.tx.us/wps/portal

Community Care for the Aged and Disabled Programs (CCAD), Community-Based Alternatives (CBA), Community Living Assistance and Support Services (CLASS), Deaf-Blind with Multiple Disabilities (DB-MD), Medically Dependent Children Program (MDCP), Consolidated Waiver Program (CWP), Home and Communi-ty-Based Services (HCS), Texas Home Living Waiver (TxHmL), and Hospice ProgramsCLASS Program CLASS Interest Line

1-512-438-3078, ext. 3530 1-877-438-5658

DB-MD Program DB-MD Interest Line

1-512-438-2622 1-877-438-5658

Waiver/CCAD financial or functional eligibility criteria

Caseworker or Case Manager

Waiver/CCAD service authorization issues Caseworker or Case ManagerWaiver/CCAD Program policies/procedures Contract ManagerHospice policy questions 1-512-438-3519 or 1-512-438-2489Hospice Program service authorization issues Provider Claims Services: 1-512-438-2200, Option 1

Website: https://hhsportal.hhs.state.tx.us/wps/portalHome and Community-Based Services (HCS) and Texas Home Living Waiver (TxHmL) billing, policy, payment reviews

Billing: Misti Ackermann, 1-512-438-4934 Prior approval AA/MHM/Dental: Virginia Sifuentes, 1-512-438-4974

Invalid or inappropriate CCAD recoupments Provider Claims Services: 1-512-438-2200, Option 4Intermediate Care Facility for Persons with Mental Retardation (ICF-MR) and Nursing Facility Programs Cost report payments 1-512-438-4475


Provider Resources

If you have questions about… Contact…

Quality assurance fee (QAF) 1-512-438-3597 or 1-512-438-3624Health and Human Services Commission Network (HHSCN) connection problems

1-512-438-4720

ICF-MR/durable medical equipment (DME), DME authorizations, Home and Community-Based Services (HCS), Texas Home Living Waiver (TxHmL), home modifications, adaptive aids, and dental services approvals

Provider Claims Services: 1-512-438-2200, Option 5 E-mail: [email protected]

ICF-MR/Residential Care (RC) individual movements/service authorization questions

1-512-438-4720: request HHSC Field Support staff

Client Assessment Registration (CARE) System Help Desk for ICF-MR

1-888-952-4357

Program enrollment for utilization review (UR)/usual, customary utilization control (UC), Purpose Codes, and Mental Retardation-Related Condition (MRRC) Assessment Form, level of service, level of need, level of care, and Inventory for Client and Agency Planning (ICAP)

1-512-438-5055 Fax: 1-512-438-4249

Provider contracts and vendor holds for ICF-MR 1-512-438-3544Vendor Holds for HCS/TxHmL 1-512-438-3652Provider access to ICF-MR CARE system ICF/MR: 1-512-438-3554

HCS: 1-512-438-5428MDS 2.0, MDS Purpose Code E, and Forms 3618 and 3619 missing/incorrect information

Provider Claims Services: 1-512-438-2200, Option 1 Website: https://hhsportal.hhs.state.tx.us/wps/portal

Rehabilitation and specialized therapy/emergency dental/Customized Power Wheelchair (CPWC) service authorizations

Provider Claims Services: 1-512-438-2200, Option 6 Fax: 1-512-438-2302

Service authorizations for nursing facilities Provider Claims Services: 1-512-438-2200, Option 1 Note: For Customized Power Wheelchairs use Option 6 Fax: 1-512-438-2301 Website: https://hhsportal.hhs.state.tx.us/wps/portal

Invalid or inappropriate recoupments for ICF-MRs Provider Claims Services: 1-512-438-2200, Option 3Consumer Rights and Services

Surrogate Decision Making Program (SDMP) for people receiving community-based services through the ICF/MR program

Consumer Rights and Services: 1-800-458-9858 E-mail: [email protected] Website: www.dads.state.tx.us (click on Complaint Intake and Consumer Rights)


Provider Resources

Index of Articles in Past IssuesArticle Name LTC Bulletin Page

Provider News: Postings Provide Useful Reference Information May 2009, No. 38 2ICM Program Transitioning from Evercare to Texas Department of Aging and Disability Services

May 2009, No. 38 2

MDS 2.0 to 3.0 Delayed May 2009, No. 38 4Expansion of the CDS Option in the Medically Dependent Children Program (MDCP) to Respite and Adjunct Support Services Provided by a Nurse

May 2009, No. 38 5

Center for Policy and Innovation, Quality Assurance and Improvement Workshops May 2009, No. 38 6Reminder: RUG Hold Harmless Feature May 2009, No. 38 6Spring 2009 LTC Workshops Announced May 2009, No. 38 7Avoid Miscellaneous Claims; Start Preparing for FY10 May 2009, No. 38 8TexMedConnect Upgrade Aug. 2009, No. 39 2Summer/Fall 2009 LTC Workshops Announced Aug. 2009, No. 39 2TexMedConnect Computer-Based Training Now Being Planned Aug. 2009, No. 39 3Reminder of Consumer-Directed Services Changes Effective September 2009 Aug. 2009, No. 39 4Center for Policy and Innovation, Quality Assurance and Improvement Symposium Aug. 2009, No. 39 4Reminder: RUG Hold Harmless Feature Aug. 2009, No. 39 5MDS 2.0 Enhancements Aug. 2009, No. 39 5MDS 3.0 Update Aug. 2009, No. 39 6Batch ID Change Provider Notification Aug. 2009, No. 39 7Claim Processing Deadlines Reminder Aug. 2009, No. 39 7Avoid Miscellaneous Claims for FY07 Services Aug. 2009, No. 39 8Claims for Different FYs Cannot be Combined Aug. 2009, No. 39 8Consolidated Waiver Program (CWP) Changes Nov. 2009, No. 40 2Prior Authorization Changed for Nonemergency Ambulance Transport Nov. 2009, No. 40 2TexMedConnect Computer-Based Training Now Being Planned Nov. 2009, No. 40 3Center for Policy and Innovation, Quality Assurance and Improvement Workshops Nov. 2009, No. 40 3State Schools Name Changed to State Supported Living Centers Nov. 2009, No. 40 3Reminder: RUG Hold Harmless Feature Nov. 2009, No. 40 4MDS 3.0 Update Nov. 2009, No. 40 4LTC Online Portal Enhancements Nov. 2009, No. 40 5Facility Requests for Nonemergency Ambulance Prior Authorization Feb. 2010, No. 41 2New Long Term Care Online Portal User Manuals Offer Online Reference Information for Providers

Feb. 2010, No. 41 2

Spring 2010 LTC Workshops Announced Feb. 2010, No. 41 2Center for Policy and Innovation, Quality Assurance and Improvement Workshops Feb. 2010, No. 41 3TexMedConnect Computer-Based Training Coming Soon Feb. 2010, No. 41 4Reminder: RUG Hold Harmless Feature Feb. 2010, No. 41 4MDS 3.0 Update Feb. 2010, No. 41 4Helpful Tips for Submitting Forms and Assessments via the LTC Online Portal to Facilitate Timely Reimbursement

Feb. 2010, No. 41 5


Provider Resources

Acronyms In This IssueAcronym DefinitionABD Aged, Blind, and DisabledANSI American National Standards InstituteCARE Client Assessment RegistrationCBA Community-Based Alternatives ProgramCBT Computer-Based TrainingCCAD Community Care for Aged and Disabled ProgramsCLASS Community Living Assistance and Support ServicesCMS Claims Management SystemCMS U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid

ServicesCPWC Customized Power WheelchairsCSI Claim Status InquiryCWP Consolidated Waiver ProgramDADS Department of Aging and Disability ServicesDAHS Day Activity and Health ServicesDB-MD Deaf-Blind with Multiple DisabilitiesDLN Document Locator NumberDME Durable Medical EquipmentEDI Electronic Data InterchangeEOB Explanation of BenefitsER&S Electronic Remittance and StatusFTP File Transfer ProtocolFY Fiscal YearHCS Home and Community-Based ServicesHHS U.S. Department of Health and Human ServicesHHSC Health and Human Services CommissionHHSCN Health and Human Services Commission NetworkHIPAA Health Insurance Portability and Accountability ActICAP Inventory for Client and Agency PlanningICF-MR Intermediate Care Facilities for the Mentally Retarded

ICMW Integrated Care Management 1915(c) Waiver

IEE Integrated Eligibility and EnrollmentLTC Long Term Care

LTCMI Long Term Care Medicaid InformationLTSS Long-Term Services and Support

MDCP Medically Dependent Children’s Program

MDS Minimum Data Set


Provider Resources

Acronym DefinitionME Medicaid Eligibility

MESAV Medicaid Eligibility Service Authorization Verification

MN Medical Necessity

MN and LOC Medical Necessity and Level of Care

MR/RC Mental Retardation-Related Condition

NF Nursing Facility

NPI National Provider Identifier

PACE Program of All-Inclusive Care for the Elderly

PASARR Pre-Admission Screening and Resident Review

PCCM Primary Care Case Management

PCS Provider Claims Services

PDF Portable Document Format

PHC Primary home Care

QAF Quality Assurance Fee

QI Quality Indicator

RAI HHS Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument

RC Residential Care

R&S Remittance and Status

RFP Request for Proposal

RN Registered Nurse

RUG Resource Utilization Group

SAS Service Authorization System

SDMP Surrogate Decision-Making Program

STAR State of Texas Access Reform

TMHP Texas Medicaid & Healthcare Partnership

TPR Third-Party Resources

TxHmL Texas Home Living Waiver

TXST Texas State University

UC Utilization Control

UR Utilization Review


Provider Resources

LTC BulletinPRSRT STD

U.S. POSTAGEPAID

TMHP

Documents

May 2010 LTC Provider Bulletin No. 42 - TMHP.com